Learning from major accidents to improve system design

Safety Science

Volumn 84, Issue , 2016, Pages 37-45

  Moura, Raphael ^a,b   Beer, Michael ^a,b   Patelli, Edoardo ^a,b   Lewis, John ^a,b   Knoll, Franz ^b,c  

^a UNIVERSITY OF LIVERPOOL   (United Kingdom)

^b NCK Inc ^*  (Canada)

^c INSTITUTE FOR RESEARCH IN IMMUNOLOGY AND CANCER   (Canada)

Author keywords

Accident analysis; CREAM; Human factors; Human reliability analysis; MATA D; Risk safety in design

Indexed keywords

ACCIDENTS; BEHAVIORAL RESEARCH; DESIGN; ERROR ANALYSIS; HUMAN ENGINEERING; INDUSTRIAL HYGIENE; OCCUPATIONAL DISEASES; RELIABILITY; RISK ASSESSMENT; SAFETY ENGINEERING; SYSTEMS ANALYSIS;

ACCIDENT ANALYSIS; CATASTROPHIC CONSEQUENCES; COGNITIVE RELIABILITY; CREAM; DESIGN IMPROVEMENTS; HUMAN RELIABILITY ANALYSIS; INDUSTRIAL ACCIDENT; INTEGRATED INFORMATIONS;

RELIABILITY ANALYSIS;

ACCIDENT; ARTICLE; COGNITIVE RELIABILITY AND ERROR ANALYSIS METHOD; CONCEPTUAL FRAMEWORK; ERROR; HUMAN; INDUSTRY; INFORMATION PROCESSING; MULTI ATTRIBUTE TECHNOLOGICAL ACCIDENTS DATASET; PRIORITY JOURNAL; PROCESS DESIGN;

EID: 84949637860     PISSN: 09257535     EISSN: 18791042     Source Type: Journal    
DOI: 10.1016/j.ssci.2015.11.022     Document Type: Article

References (35)

1. Bell, J., 2012. The Gulf Spill: BP still doesn't get it. In: Allen, F.E. (Ed.), Forbes, 20 April 2012. http://www.forbes.com/sites/frederickallen/2012/04/20/the-gulf-spill-bp-still-doesnt-get-it/.
2. Bell J., Holroyd J. Review of Human Reliability Assessment Methods 2009, HSE Books, Suffolk.
3. Bellamy L.J., et al. Storybuilder-A Tool for the Analysis of Accident Reports. Reliab. Eng. Syst. Saf. 2007, 92:735-744.
4. Bellamy L.J., et al. Analysis of underlying causes of investigated loss of containment incidents in Dutch Seveso plants using the Storybuilder method. J. Loss Prevent. Process Ind. 2013, 26:1039-1059.
5. Blajev T. SOFIA (Sequentially Outlining and Follow-up Integrated Analysis) Reference Manual 2002, EATMP Infocentre, Brussels.
6. Bureau d'Enquêtes et d'Analyses pour la sécurité de l'aviation civile, 2011. Final Report on the Accident on 1st June 2009 to the Airbus A330-203 [Online]. Available from: (accessed: 06 November 2014). http://www.bea.aero/docspa/2009/f-cp090601.en/pdf/f-cp090601.en.pdf.
7. Cooper S., et al. A Technique for Human Error Analysis (ATHEANA) - Technical Basis and Methodology Description 1996, US Nuclear Regulatory Commission Library, Washington, D.C.
8. Everdij, M., Blom, H., 2013. Safety Methods Database version 1.0 [Online]. National Aerospace Laboratory (NLR), Amsterdam. Available from: (accessed: 9 April 2014). http://www.nlr.nl/downloads/safety-methods-database.pdf.
9. Fowler, T., 2013. BP faces new bout of spill liability. The Wall Street Journal, 18 February 2013. Dow Jones & Company Inc., New York.
10. Gibson W.H., Megaw T.D. The Implementation of CORE-DATA, A Computerised Human Error Probability Database 1999, HSE Books, Suffolk.
11. Grabowski M., et al. Human and organizational error data challenges in complex, large-scale systems. Saf. Sci. 2009, 47:1185-1194.
12. Hollnagel E. Cognitive Reliability and Error Analysis Method 1998, Elsevier Science Ltd., Oxford.
13. Hopkins A. The limits of normal accident theory. Saf. Sci. 1999, 32:93-102.
14. International Atomic Energy Agency, 1990. Human error classification and data collection. Report of a Technical Committee Meeting Organised by the IAEA, Vienna, 20-24 February 1989, INIS Clearinghouse, Vienna.
15. Kirwan B. Validation of human reliability assessment techniques: Part 1-validation issues. Saf. Sci. 1997, 27:25-41.
16. Kirwan, B., James, N.J., 1989. Development of a human reliability assessment system for the management of human error in complex systems. In: Proceedings of the Reliability '89, Brighton, 14-16 June, pp. 5Al2/1-5A/2/11.
17. Kirwan B., et al. Nuclear action reliability assessment (NARA): a data-based HRA tool. Saf. Reliab. 2005, 25(2):38-45.
18. Kurokawa, K., et al., 2012. The Official Report of The Fukushima Nuclear Accident Independent Investigation Commission - Executive Summary [Online]. The National Diet of Japan, Tokyo. Available from: (accessed: 6 November 2014). https://www.nirs.org/fukushima/naiic_report.pdf.
19. Licu T., et al. Systemic Occurrence Analysis Methodology (SOAM) - a "Reason"-based organisational methodology for analysing incidents and accidents. Reliab. Eng. Syst. Saf. 2007, 92:1162-1169.
20. Moura, R., et al., 2015. Human error analysis: review of past accidents and implications for improving robustness of system design. In: Nowakowski, T., et al. (Eds.), Proceedings of the 24th European Safety and Reliability Conference, 14-18 September 2014, Wroclaw, Taylor & Francis Group, London, pp. 1037-1046.
21. National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling, 2011. The Gulf Oil Disaster and the Future of Offshore Drilling - Report to the President [Online]. U.S. Government Printing Office, Washington D.C. Available from: (accessed: 20 July 2015). http://www.gpo.gov/fdsys/pkg/GPO-OILCOMMISSION/pdf/GPO-OILCOMMISSION.pdf.
22. Pennycook, W., Embrey, D., 1993. An operating approach to error analysis. In: Proceedings of the First Biennial Canadian Conference on Process Safety and Loss Management, April, Edmonton, Canada.
23. Rasmussen J. Skills, rules, and knowledge; signals, signs, and symbols, and other distinctions in human performance models. IEEE Trans. Syst., Man Cybernetics 1983, SMC-13(3).
24. Reason J. Human Error 1990, Cambridge University Press, Cambridge.
25. Reason J. Managing the Risks of Organizational Accidents 1997, Ashgate, Brookfield, USA.
26. Shappell S., et al. Human error and commercial aviation accidents: an analysis using the human factors analysis and classification system. Hum. Factors 2007, 49(2):227-242.
27. Sträter, O., 2000. Evaluation of Human Reliability on the Basis of Operational Experience. GRS, Cologne (English translation of the Report GRS-138: Beurteilung der menschlichen Zuverlassigkeit auf Basis von Betriebserfahrung.).
28. Swain, A., 1963. A Method for Performing Human Factors Reliability Analysis. Monograph-6851, Sandia National Laboratories, Albuquerque.
29. Swain, A. 1982. Modeling of response to nuclear power plant transients for probabilistic risk assessment. In: Proceedings of the 8th Congress of the International Ergonomics Association, August, Tokyo.
30. Swain A. Human reliability analysis - need, status, trends and limitations. Reliab. Eng. Syst. Saf. 1990, 29:301-313.
31. Swain A., Guttmann H. NUREG/CR 1278 - Handbook of Human Reliability Analysis with Emphasis on Nuclear Power Plant Applications 1983, Sandia National Laboratories, Albuquerque.
32. The Control of Major Accident Hazards Regulations, 1999. National Archives, Surrey. http://www.legislation.gov.uk/uksi/1999/743/contents/made.
33. The Offshore Installations (Safety Case) Regulations, 2005. National Archives, Surrey. http://www.legislation.gov.uk/uksi/2005/3117/made.
34. US Chemical Safety and Hazard Investigation Board Case Study 2004-08-I-NM Oil Refinery Fire and Explosion 2005, CSB Publications, Washington, DC.
35. Williams, J.C., 1986. HEART - a proposed method for assessing and reducing human error. In: Proceedings of the 9th Advances in Reliability Technology Symposium, Bradford, 2-4 April 1986, National Centre of Systems Reliability, Warrington.